Description

The endometrium is the tissue that lines the womb (uterus). This thickens during a menstrual cycle and breaks down on a monthly basis and is shed during the menstrual period. Endometriosis is a condition characterised by the growth of endometrial tissue in abnormal sites. Most commonly patches of endometriosis grow outside the uterus in the pelvic area but they can occur in almost any site in the body e.g. on the bowel, in the bladder and in the lungs. At the time of a menstrual period when the endometrium breaks down, the spots of endometriosis can bleed causing pain and inflammation and result in adhesions and sub-fertility. One in ten women will suffer with endometriosis during their reproductive life span. It is more likely to occur in women whose relatives have had the condition. Frequently endometriosis is a condition that worsens with time and may re-occur after treatment.Endometriosis can occur on the surface of the ovaries and also within the ovaries themselves. In this situation they can form blood filled cysts called endometriomas (chocolate cysts). Endometriosis can be classified into four stages based on it severity with Stage 1 being the least severe and Stage 4 being the most severe. With Stage 4 disease the organs adjacent to the uterus such as the bowel and bladder are usually involved.

Symptoms

The most common symptom is pain in the pelvic area at the time of the menstrual period.  The degree of pain can vary from mild to very severe.  The severity of the pain does not necessarily relate to the stage of the disease.  Other symptoms that may be present are:

  • Pain during ovulation
  • Pain during sexual intercourse
  • Painful periods
  • Heavy prolonged or irregular bleeding
  • Spotting before or after periods
  • Difficulty in conceiving (sub-fertility)

If patches of endometriosis are present in other parts of the body, other symptoms or signs may be present. For example there may be blood in the urine and also pain on passing urine if endometriosis is situated in the bladder. There may be bleeding from the rectum and pain on defecation if the bowel is affected. Endometriotic nodules may form in the skin or in surgical scars and present as painful lumps. Occasionally patients may present with coughing up blood if endometriosis is present in the lungs. Most of these problems occur on a cyclical basis at the time of the menstrual period.

Diagnosis

Patients suffering with pelvic pain, irregular bleeding or period problems will need to have an ultrasound scan performed.  This is best done by the transvaginal route as it will give a clear picture of the uterus, endometrium and ovaries.  Ovarian cysts and endometriomas can normally be diagnosed this way.The only way to confirm a diagnosis of endometriosis is to perform a laparoscopy (keyhole surgery).  This involves placing a tube (laparoscope) through a small incision in the abdominal wall under general anaesthesia attached to a camera.  It is normally possibly to treat endometriosis by this method as well.  Laparoscopy is normally performed as a day case procedure so that patients can go home the same day as surgery.

Treatments

Endometriosis Treatment
Endometriosis can be treated in a variety of ways but the majority of cases can be treated at the time of diagnosis by keyhole surgery.  Other treatments may also be used in conjunction with surgery.
Treatments
Anti-inflammatory drugs.
Combined oral contraceptive pill – taken continuously for six to nine months to prevent menstrual bleeding.
Progesterone therapy taken for six to nine months continuously to stop menstrual periods.
GNRH analogues – these drugs can be taken as a nasal spray or a monthly or three monthly injection to create a temporary “menopause”.Surgical Treatment
This is the most effective form of treatment. Surgical treatment of endometriosis is usually performed by laparoscopy (keyhole surgery). Superficial patches of endometriosis on the peritoneum may be treated with diathermy or be excised.  Where there are deep nodules of endometriosis, surgery is more extensive and may involve excision of small parts of the bowel.  Where fertility is no longer required and in severe debilitating cases, hysterectomy and oophorectomy (removal of the womb and ovaries) may be necessary.  When there is advanced disease open surgery may be required.  The incidence of complications from surgery is very low.  However injuries to adjacent organs such as the bowel, bladder and ureters can occur.